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Depression In The Elderly PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Depression in the elderly” by James T. Birch, Jr., MD, MSPH.

This medical PowerPoint presentation is about the issue of depression in the elderly.

Depression is a common mental health condition that affects people of all ages, including the elderly. In fact, depression in the elderly is a significant public health concern, as it can lead to a decline in physical health, cognitive impairment, and an increased risk of suicide.

There are several factors that can contribute to depression in the elderly, including social isolation, chronic illness, and changes in life circumstances such as retirement, the loss of a loved one, or a decline in physical health.

Treatment for depression in the elderly may include medication, psychotherapy, or a combination of both. It is also important for elderly individuals with depression to engage in regular physical activity, eat a healthy diet, and maintain social connections with friends and family.

If you or a loved one is experiencing symptoms of depression, it is important to seek help from a healthcare professional. Depression is a treatable condition, and with the right support and treatment, older adults can regain their sense of well-being and lead fulfilling lives.

Tags : Depression, mental health condition, Neurology, Neurology PowerPoint presentation

Published on : Jun 20, 2023 | Views : 2204 | Downloads : 0

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Slide 1-

DEPRESSIONIN THE ELDERLY Module developed by James T. Birch, Jr., MD, MSPH Assistant Clinical Professor Dept. of Family Medicine, Division of Geriatric Medicine Landon Center on Aging University of Kansas Medical Center
Slide 2-

Objectives Review the diagnostic criteria for depression Increase awareness of the prevalence and consequences of untreated depression in the older adult Discuss screening, treatment, and follow-up for those who have depression
Slide 3-

Content 1. Define depression 2. Review the epidemiology of depression in the elderly. 3. Risk Factors 4. Recognition of signs and symptoms 5. Differential Diagnosis 6. Screening Tools 7. Treatment 8. Review the consequences/complications of inadequately treated depression. 9. ACOVE – 3 Indicators
Slide 4-

Introduction Depression is under-recognized and undertreated in the older adult Many older adults who die by suicide (up to 75%) suffer with depression and most visited a physician within a month before death Untreated depression can delay recovery or worsen the outcome of other medical illnesses via increased morbidity or mortality Depression is NOT a part of normal aging
Slide 5-

What is Depression? DSM-IV-TR Definition Five or more of the following must have been present during the same 2-week interval and represent a change from baseline functioning One(1) of the symptoms must be depressed mood or loss of interest or pleasure Geriatric Nursing (26)3;2005
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What is Depression? DSM-IV-TR (a.k.a. “core symptoms”; occur most of the day nearly every day) Depressed mood Loss of interest in all or almost all activities or pleasure (anhedonia) Appetite change or weight loss Insomnia or hypersomnia Psychomotor agitation or retardation
Slide 7-

What is Depression? DSM-IV-TR (cont.) Loss of energy or fatigue Feelings of worthlessness or excessive guilt Difficulty with thinking, concentration, or decision making Recurrent thoughts of death or suicide Preoccupation with somatic symptoms, health status, or physical limitations
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What is Depression? For Major Depression, these symptoms Produce social impairment Are not related to substance abuse Are not related to bereavement
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What is Depression? Types of Depressive Disorders (DSM-IV) Mild episode of major depression Moderate episode of major depression Severe episode of major depression Severe episode of major depression with psychotic features AMDA Clinical Practice Guideline
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What is Depression? Minor depression is common 15% of older persons Causes  use of health services, excess disability, poor health outcomes, including  mortality Major depression is not common 1%–2% of physically healthy community dwellers Elders less likely to recognize or endorse depressed mood
Slide 11-

What is Depression “Late-life” depression (a geriatric syndrome) is a recurrence of depressive symptoms that initially occurred during early adulthood. there is no known or identifiable precipitating factor. patients usually have no family history of depression. Depressed mood is not required to meet criteria for major depressive disorder.
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Epidemiology (of major depression) Community-Dwelling 1 - 9 % Primary Care Settings 10 – 12 % Hospitalized 11 – 45 % Nursing Home 10-26% Permanent Placement Up to 43%
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Risk Factors Alcohol or substance abuse Current use of a medication associated with a high risk of depression Hearing or vision impairment severe enough to affect function History of attempted suicide History of psychiatric hospitalization
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Risk factors Medical diagnosis or diagnoses associated with a high risk of depression New admission or change of environment New stressful losses (loss of autonomy, privacy, functional status, body part, family member or friend) Personal or family history of depression or mood disorder
Slide 15-

What medications do YOU prescribe for older adults that might place them at risk for DEPRESSION ?
Slide 16-

Medications that may cause symptoms of Depression Anabolic steroids Anti-arrhythmic medications (amiodarone, mexilitine) Anticonvulsant medications Barbiturates Benzodiazepines Carbidopa or levodopa Certain beta-adrenergic antagonists (i.e. propranol)
Slide 17-

Medications that may cause symptoms of Depression Clonidine Cytokines (specifically IL-2) Digitalis preparations Glucocorticoids (prednisone) H2 blockers Metoclopramide Opioids
Slide 18-

Laboratory Tests for Evaluation CMP (lytes, BUN, creat, Ca++, glucose) CBC Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline Thyroid function (T3, T4, TSH) EKG Folate level UA Vitamin B12
Slide 19-

Differential Diagnosis Thyroid disorders (hypo- and hyper-thyroidism) Dementia (or mild cognitive impairment) Bereavement Anxiety Disorder Substance Abuse Disorder Personality Disorder Diabetes mellitus Underlying malignancy Anemia Medication side effects
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Differential Diagnosis DEPRESSION Subacute onset Family recognition early Rapid progression Impairment inconsistent over time Pt admits deficits Appears depressed Anhedonia Abstract thought usually normal “I don’t know” response to questions Pt often unconcerned DEMENTIA Insidious onset Delayed family recognition Slow progression Impairment consistent; slow, gradual decline Pt denies/unaware of deficits Not depressed Can experience pleasure Abstract thought impaired Near miss answers Pt tries to cover up
Slide 21-

What is the most commonly used and validated screening tool for diagnosis of Depression in the elderly patient? The Geriatric Depression Scale
Slide 22-

Screening Tools Geriatric Depression Scale (GDS; validated) 15 item scale ( > 5 points or positive responses is diagnostic) Cornell Scale for Depression in Dementia (scoring system: >12 means probable depression) Center for Epidemiologic Studies of Depression Scale (CES-D) Patient Health Questionnaire 9 (9 item self-rating scale) AMDA Clinical Practice Guideline
Slide 23-

Screening Tools Two – item scale (PHQ-2): During the previous 2 weeks…….. 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you often been bothered by having little interest or pleasure in doing things? (“Yes” answer to either is considered positive) Sensitivity: 100%; Specificity:77%; PPV: 14% NEJM: 357:22; 11/29/07
Slide 24-

Treatment The consequences of depression in the elderly require serious attention because of the disproportionately high risk of suicide For the year 2000, 13% of the U.S. population was 65 and older, and the suicide rate accounted for 18% of all suicides Geriatric Nursing (26)3: 2005 http://www.cdc.gov/ncipc/wisqars/default.htm
Slide 25-

Treatment Goals of therapy: improve mood, function, and quality of life Goals of treatment of an acute depressive episode are to achieve recovery and prevent future episodes of depression The intended outcome should be complete resolution of symptoms, not simply a reduction in depressive symptoms. Three phases of treatment are generally required to achieve these goals.
Slide 26-

Treatment Acute Phase (reverse current episode) Duration: about 3 months: Goal is complete recovery from signs and sx of acute episode Continuation Phase (prevent a relapse) Duration: 4-6 months: Goal is to prevent relapse as sx continue to decline and functionality improves Maintenance Phase (prevent future recurrence) Duration: 3 months or longer: Goal is to prevent recurrence of a new depressive episode
Slide 27-

Treatment Pharmacotherapy Psychotherapy Electroconvulsive therapy (ECT)
Slide 28-

Treatment Patients should be monitored for response to treatment by: Observation for resolution of signs and symptoms of depression Documenting improvement in scores on screening tools Improvement in attendance at and participation in usual activities Improvement in sleep pattern Also monitor patients carefully for side effects and interactions with other medications
Slide 29-

Treatment : Pharmacotherapy Antidepressants SSRI’s Celexa (citalopram) 20-40mg/day Lexapro (ecitalopram) 10-20mg/day Prozac (fluoxetine) 20-40mg q am Paxil (paroxetine) 10-40mg q am or q hs Zoloft (sertraline) 50-200mg q am Better tolerated than tricyclics SIADH at high doses and sexual side effects Interact with CYP-450 isoenzymes by inhibition Can increase the anticoagulant effect of warfarin Do not discontinue abruptly; taper the dose
Slide 30-

Treatment : Pharmacotherapy Antidepressants (SSRIs continued) Nausea and diarrhea might occur Fluoxetine is not a preferred drug for use in the elderly due to a prolonged half life (4-6 days; metabolite 9.3 days) and potential for many drug interactions. It might also induce anxiety, sleep disturbance, and/or agitation Paroxetine is also not favored due to anti-cholinergic properties and other effects noted with fluoxetine
Slide 31-

Treatment : Pharmacotherapy Antidepressants Tricyclics (secondary amines) Norpramin (desipramine) 20-150 qd / q hs Pamelor, Aventyl (nortriptyline) 20 – 100 mg q hs Potential for anticholinergic and sedative effects Avoid in pts. who are prone to constipation, orthostatic hypotension, glaucoma, or who have BPH May cause ventricular conduction delays and heart block May be fatal in overdose
Slide 32-

Treatment : Pharmacotherapy Antidepressants Bicyclics Effexor (venlafaxine) 75 mg BID Effexor XR 75 – 100mg qd Fewer drug interactions Can cause or aggravate hypertension Pts. are at risk for withdrawal syndrome
Slide 33-

Treatment : Pharmacotherapy Antidepressants SNRI and SSRI Cymbalta (duloxetine) 30-60 mg/day Norepinephrine, 5HT2 and 5HT3 antagonist Remeron (mirtazapine) 15-45 mg q hs Can cause serotonin syndrome when given with other SSRI’s
Slide 34-

Treatment : Pharmacotherapy Antidepressants Norepinephrine-dopamine reuptake inhibitor Wellbutrin (bupropion) 100 mg TID Wellbutrin SR 150 mg BID Serotonin antagonist and reuptake inhibitor Serzone (nefazodone) 150mg BID Desyrel (trazodone) 50 – 200mg q hs
Slide 35-

Treatment : Pharmacotherapy Antidepressants Stimulants Ritalin (methylphenidate) 20mg BID Provigil (modafinil) 400mg q am Dexedrine (dextroamphetamine) 2.5-5mg 7am and noon
Slide 36-

Treatment : Pharmacotherapy Antidepressants Monoamine Oxidase Inhibitors (MAOIs) Marplan (isocarboxazid) 30 mg/day Nardil (phenelzine) 30–45 mg/day Parnate (tranylcypromine) 30–40 mg/day Orthostatic hypotension, falls Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies (pressor amine) Fatal serotonin syndrome possible if taken with SSRI, meperidine
Slide 37-

Treatment Should the elderly patient experiencing bereavement be treated for Depression? NO! However, if symptoms of MAJOR DEPRESSION persist for more than 2 months after the loss, treatment for depression should be strongly considered. Unutzer, J. NEJM, Nov. 29, 2007
Slide 38-

Treatment : Psychotherapy Cognitive-behavioral Interpersonal Short-term psychodynamic Life review, reminisce Problem solving Supportive Bereavement therapy Behavioral Dialectical-behavioral therapy
Slide 39-

Treatment : Psychotherapy Individualize standard approaches Cognitive-behavioral therapy Interpersonal psychotherapy Problem-solving therapy Combination with an antidepressant has been shown to extend remission after recovery Watch for depressive syndromes in caregivers, who might benefit from therapy
Slide 40-

Treatment : Psychotherapy Individualize choice of drug on basis of: Patient’s comorbidities Drug’s side-effect profile Patient’s sensitivity to these effects Drug’s potential for interacting with other medications
Slide 41-

Treatment : ECT For depression with pronounced psychotic features and resistance to standard medical therapy Effective for treatment of major depression & mania; response rates exceed 70% in older adults
Slide 42-

Treatment : ECT First-line treatment for patients at serious risk for suicide, life-threatening poor intake Standard for psychotic depression in older adults; response rates 80%
Slide 43-

Treatment : ECT Side Effects Anterograde amnesia improves rapidly after treatment Retrograde amnesia is more persistent; recall of events just before treatment may be lost permanently Lasting effects not shown in longitudinal studies Right unilateral treatment: fewer side effects but less effective than bilateral
Slide 44-

Treatment : ECT Contraindications Increased intracranial pressure Recent MI or CVA and unstable CAD increase risk of complications Continue pharmacotherapy following completion of ECT treatment May use maintenance ECT to prevent relapse
Slide 45-

Treatment Response 40% of cases of major depression respond to initial pharmacotherapy within 6 weeks Additional 15% to 25% achieve remission with continued treatment for 6 weeks GRS, 2006 Monotherapy fails 35-45% Responsive to initial pharmacotherapy 40% Responsive to continued treatment 15-25%
Slide 46-

Treatment Response The most common prescribing error is failure to increase the dose to the recommended level within the first 2 weeks of treatment When monotherapy fails: Consider switch to another drug class Combine lithium carbonate, methylphenidate, or triiodothyronine with secondary amine TCA Add psychotherapy Consult a geriatric psychiatrist
Slide 47-

Treatment Response Reasons for partial response or treatment failure Dementia that is confused with or accompanied by late life depression Concurrent psychosis (interferes with diagnosis and treatment of depression) Compliance is difficult when patients are depressed www.medscape.com/viewarticle/41887
Slide 48-

Consequences and Complications of Inadequately Treated Depression Recurrence, partial recovery, and chronicity . . .  disability  use of health care resources  morbidity and mortality Suicide (one fourth of all suicides occur in persons  65)
Slide 49-

Consequences and Complications of Inadequately Treated Depression Which demographic in the elderly population has the highest risk and incidence of suicide? Highest: white males age 80 & older Next highest: white males between 65 and 80 AMDA Guidelines
Slide 50-

Consequences and Complications of Inadequately Treated Depression Suicide: Ask the patients about thoughts of hurting themselves; if YES, ask whether they have a plan; if YES, ask what it is; then ask about stockpiled medications or weapons in the home. Patients with a plan require emergent psychiatric evaluation in ER or local crisis unit.
Slide 51-

Consequences and Complications of Inadequately Treated Depression Risk factors for suicide: depression older age physical illness living alone (single, divorced, or separated and without children) male gender drug abuse or alcoholism having a personal or family history of suicide attempt severe anxiety or stress specific plan with access to firearms or other means.
Slide 52-

Consequences and Complications of Inadequately Treated Depression Violent suicides (e.g. firearms, hanging) are more common than non-violent methods among older adults, despite the potential for drug overdosing
Slide 53-

ACOVE – 3 Quality Indicators Total of #20 IF-THEN-BECAUSE directives for care of Depression; they include: Screening for and Recognizing Depression Documenting Depression Symptoms Suicidal Ideation Evaluate for Comorbid condition Initiating Depression Treatment Antidepressant Choice
Slide 54-

ACOVE – 3 Quality Indicators Psychotic Depression Electrocardiogram for Tricyclic Use Interactions with MAOIs Depression Follow-Up The First 12 Weeks of Depression Treatment Continuing Depression Therapy
Slide 55-

ACOVE – 3 Quality Indicators Indicators #4 thru #7 were selected for review
Slide 56-

ACOVE – 3 Quality Indicators Indicator #4 : IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document at least three of the nine DSM-IV target symptoms for major depression within 2 weeks of diagnosis, BECAUSE monitoring depression treatment requires identification and reevalution of the presenting depression symptoms.
Slide 57-

ACOVE – 3 Quality Indicators Indicator #5: IF a VE receives a diagnosis of a new depression episode, THEN the medical record should document on the day of diagnosis the presence or absence of suicidal ideation and psychosis, BECAUSE suicidal patients may require hospitalization, and patients with psychotic depression may need antipsychotic medication or ECT and referral to a psychiatrist.
Slide 58-

ACOVE – 3 Quality Indicators Indicator #6: IF a VE has thoughts of suicide, THEN the medical record should document, on the same date, that the patient has no immediate plan for suicide or was referred for evaluation for psychiatric hospitalization AND…..
Slide 59-

ACOVE – 3 Quality Indicators Indicator #7: IF a VE has thoughts of suicide, THEN the medical record should document on the same date, that the patient was asked about access to firearms, BECAUSE the likelihood of suicide increases if the patient has a specific plan to commit suicide and access to firearms, and it decreases if the patient is hospitalized to receive psychiatric care.
Slide 60-

Summary All health care workers should maintain a high index of suspicion for the presence of depression or depressive symptoms in their patients. Screen older adults for depression at the initial visit
Slide 61-

Summary In older adults, depression is: Common (especially “minor” depression) Associated with morbidity Difficult to diagnose because of atypical presentation, more somatic concerns, overlap with symptoms of other illnesses Differential diagnoses include other medical illnesses, dementia, bereavement
Slide 62-

Summary Suicide is a serious concern in depressed older patients, particularly older white males Treatment (acute & preventive) should be individualized and may include: Pharmacotherapy Psychotherapy ECT Choice of antidepressant should be based on comorbidities, side-effect profiles, patient sensitivity, potential drug interactions
Slide 63-

Final thought: On the Threshold of Eternity. In 1890, Vincent van Gogh painted this picture seen by some as symbolizing the despair and hopelessness felt in depression. Van Gogh himself suffered from depression and committed suicide later that same year.
Slide 64-

References Geriatrics Review Syllabus, 6th Edition; American Geriatrics Society, 2006, Chap. 35, pp. 269-79 Nakajima, G.A., Wenger, N.S. Quality Indicators for the Care of Depression in Vulnerable Elders; JAGS: (55)S2:S302-11; Oct. 2007 Current Geriatric Diagnosis and Treatment; Landefeld, C.S., et al; McGraw-Hill Co., 2004. Chap. 14, pp. 100-107 Depression: Clinical Practice Guideline; American Medical Directors Association Buffum, M.D., et al; Treating Depression in the Elderly: An Update on Antidepressants; Geriatric Nursing 26(3): 138-142 Kotylar, M. Update on Drug-Induced Depression in the Elderly; Am J of Geriatric Pharmacotherapy 3(4):Dec. 2005; 288-300 http://www.medscape.com/viewarticle/41887 Update on Depression in the Elderly Retrieved 02/19/2009 National Institute of Mental Health; Older Adults: Depression and Suicide Facts; http://www.nimh.nih.gov/health/publications/older-adults-depression-and-suicide-facts-fact-sheet/index Unutzer, J. Late-Life Depression; NEJM 357(22): Nov. 29, 2007; pp2269-76